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Chest Aug 2023Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients...
BACKGROUND
Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations.
STUDY DESIGN AND METHODS
An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations.
RESULTS
Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement.
INTERPRETATION
Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.
Topics: Humans; Quality of Life; Respiration, Artificial; Noninvasive Ventilation; Respiratory Insufficiency; Physicians
PubMed: 36921894
DOI: 10.1016/j.chest.2023.03.011 -
Air Medical Journal 2023
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Critical Care Nursing Clinics of North... Mar 2024Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk... (Review)
Review
Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.
Topics: Infant, Newborn; Humans; Noninvasive Ventilation; Respiration, Artificial; Continuous Positive Airway Pressure; Intermittent Positive-Pressure Ventilation; Interactive Ventilatory Support
PubMed: 38296376
DOI: 10.1016/j.cnc.2023.11.001 -
Journal of Perinatology : Official... Feb 2024Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and... (Review)
Review
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
Topics: Infant; Infant, Newborn; Adult; Child; Humans; Delirium; Intensive Care Units, Neonatal; Critical Illness; Respiration, Artificial; Risk Factors
PubMed: 37684547
DOI: 10.1038/s41372-023-01767-5 -
Journal of Perinatology : Official... Nov 2023We aimed to present the active management and outcomes of infants born at 22 weeks of gestation. (Observational Study)
Observational Study
OBJECTIVE
We aimed to present the active management and outcomes of infants born at 22 weeks of gestation.
STUDY DESIGN
This retrospective observational study presented the resuscitation methods, management during hospitalization, and outcomes of 29 infants born at 22 weeks of gestation who were actively resuscitated and admitted to our center during 2013-2020.
RESULTS
The survival rate was 82.8% (24/29). Tracheal intubation was performed in all patients, and surfactant was administered for 27 (93.1%). Conventional mechanical ventilation was introduced in 27 (93.1%), and this was changed to high-frequency oscillatory ventilation in more than half by day 4. Surgical treatments of patent ductus arteriosus, necrotizing enterocolitis, and retinopathy of prematurity were required in 4 (13.7%), 3 (10.3%), and 15 (51.7%) patients, respectively. No patient required a tracheostomy or ventriculoperitoneal shunt.
CONCLUSIONS
The overall survival rate and survival rate without morbidities were high among infants born at 22 weeks of gestation.
Topics: Infant; Infant, Newborn; Humans; Pregnancy; Female; Japan; Infant, Premature; Retrospective Studies; Respiration, Artificial; High-Frequency Ventilation; Ductus Arteriosus, Patent
PubMed: 37393397
DOI: 10.1038/s41372-023-01706-4 -
Current Opinion in Critical Care Jun 2024This review explores lung recruitment monitoring, covering techniques, challenges, and future perspectives. (Review)
Review
PURPOSE OF REVIEW
This review explores lung recruitment monitoring, covering techniques, challenges, and future perspectives.
RECENT FINDINGS
Various methodologies, including respiratory system mechanics evaluation, arterial bold gases (ABGs) analysis, lung imaging, and esophageal pressure (Pes) measurement are employed to assess lung recruitment. In support to ABGs analysis, the assessment of respiratory mechanics with hysteresis and recruitment-to-inflation ratio has the potential to evaluate lung recruitment and enhance mechanical ventilation setting. Lung imaging tools, such as computed tomography scanning, lung ultrasound, and electrical impedance tomography (EIT) confirm their utility in following lung recruitment with the advantage of radiation-free and repeatable application at the bedside for sonography and EIT. Pes enables the assessment of dorsal lung tendency to collapse through end-expiratory transpulmonary pressure. Despite their value, these methodologies may require an elevated expertise in their application and data interpretation. However, the information obtained by these methods may be conveyed to build machine learning and artificial intelligence algorithms aimed at improving the clinical decision-making process.
SUMMARY
Monitoring lung recruitment is a crucial component of managing patients with severe lung conditions, within the framework of a personalized ventilatory strategy. Although challenges persist, emerging technologies offer promise for a personalized approach to care in the future.
Topics: Humans; Monitoring, Physiologic; Respiration, Artificial; Respiratory Mechanics; Lung; Electric Impedance; Tomography, X-Ray Computed; Blood Gas Analysis; Ultrasonography
PubMed: 38690956
DOI: 10.1097/MCC.0000000000001157 -
Critical Care Medicine Nov 2023
Topics: Diaphragm; Respiration, Artificial; Lung
PubMed: 37902352
DOI: 10.1097/CCM.0000000000006013 -
Respiratory Medicine Mar 2024Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of... (Review)
Review
Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.
Topics: Humans; Diaphragm; Respiration, Artificial; Ventilators, Mechanical; Respiration; Lung
PubMed: 38290603
DOI: 10.1016/j.rmed.2024.107541 -
Journal of Critical Care Aug 2023The optimal approach for transitioning from strict lung protective ventilation to support modes of ventilation when patients determine their own respiratory rate and...
BACKGROUND
The optimal approach for transitioning from strict lung protective ventilation to support modes of ventilation when patients determine their own respiratory rate and tidal volume remains unclear. While aggressive liberation from lung protective settings could expedite extubation and prevent harm from prolonged ventilation and sedation, conservative liberation could prevent lung injury from spontaneous breathing.
RESEARCH QUESTION
Should physicians take a more aggressive or conservative approach to liberation?
METHODS
Retrospective cohort study of mechanically ventilated patients from the Medical Information Mart for Intensive Care IV database (MIMIC-IV version 1.0) estimating effects of incremental interventions modifying the propensity for liberation to be more aggressive or conservative relative to usual care, with adjustment for confounding via inverse probability weighting. Outcomes included in-hospital mortality, ventilator free days, and ICU free days. Analysis was performed on the entire cohort as well as subgroups differentiated by PaO2/FiO2 ratio, and SOFA.
RESULTS
7433 patients were included. Strategies multiplying the odds of a first liberation relative to usual care at each hour had a large impact on time to first liberation attempt (43 h under usual care, 24 h (0.95 CI = [23,25]) with an aggressive strategy doubling liberation odds, and 74 h (0.95 CI = [69,78]) under a conservative strategy halving liberation odds). In the full cohort, we estimated aggressive liberation increased ICU-free days by 0.9 days (0.95 CI = [0.8,1.0]) and ventilator free days by 0.82 days (0.95 CI = [0.67,0.97]), but had minimal effect on mortality (only a 0.3% (0.95 CI = [-0.2%,0.8%]) difference between minimum and maximum rates). With baseline SOFA≥ 12 (n = 1355), aggressive liberation moderately increased mortality (58.5% [0.95 CI = (55.7%,61.2%)]) compared with conservative liberation (55.1% [0.95 CI = (51.6%,58.6%)]).
INTERPRETATION
Aggressive liberation may improve ventilator free and ICU free days with little impact on mortality in patients with SOFA score < 12. Trials are needed.
Topics: Humans; Respiration, Artificial; Ventilator Weaning; Retrospective Studies; Intensive Care Units; Time Factors
PubMed: 36796189
DOI: 10.1016/j.jcrc.2023.154275 -
Seminars in Fetal & Neonatal Medicine Oct 2023Interest in 'resurrecting' the lifeless by supporting breathing has been described since ancient times. For centuries, methods of resuscitating animals, then humans and... (Review)
Review
Interest in 'resurrecting' the lifeless by supporting breathing has been described since ancient times. For centuries, methods of resuscitating animals, then humans and specifically the 'lifeless' neonate were debated and discussed. Over time, with experimentation and worldwide collaboration, endotracheal tubes and laryngoscopes specific to the newborn were created and their use refined. This historical work has meant that today, the neonatal community focuses on refining the science and the art of intubation for the benefit of the newborn; who, where, when and how to intubate, with what devices and medications, bringing about significant change in the area of neonatal intubation. Recent work has focused on alternatives to neonatal intubation as the risks of endotracheal intubation and mechanical ventilation have become clearer. Appreciating the history of neonatal intubation and its (somewhat cyclical) changes over time can show us how far we've come and how far we can still go in the resuscitation and respiratory support of newborns.
Topics: Infant, Newborn; Humans; Resuscitation; Laryngoscopes; Intubation, Intratracheal; Respiration, Artificial; Respiration
PubMed: 38030436
DOI: 10.1016/j.siny.2023.101481